military dermatology, chapter 1, historical overview and

Historical Overview and Principles of Diagnosis

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HISTORICAL OVERVIEW ANDPRINCIPLES OF DIAGNOSIS

Chapter 1

LARRY E. BECKER, M.D.* AND WILLIAM D. JAMES, M.D.

HISTORICAL OVERVIEWWorld War IWorld War IIVietnam ConflictLessons Not LearnedRecommendations

PRINCIPLES OF DIAGNOSISAnatomyPhysical ExaminationPatient HistoryDifferential Diagnostic Considerations

SUMMARY

*Colonel, Medical Corps, U.S. Army; Chief, Dermatology Service, Brooke Army Medical Center, Fort Sam Houston, Texas 78234-6200, andConsultant in Dermatology to The U.S. Army Surgeon General

Colonel, Medical Corps, U.S. Army; Chief, Dermatology Service, Walter Reed Army Medical Center, Washington, D.C. 20307-5001

Military Dermatology

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HISTORICAL OVERVIEW

Skin diseases are of major importance in militaryoperations. Although they cause few fatalities, theyare a significant cause of combat ineffectiveness,troop morbidity, and poor morale. Widespreadscabetic infestation, as detailed in Chapter 8, Ar-thropod and Other Animal Bites, is an excellentexample of a skin disease with these repercussions;successful completion of unit missions has beencompromised repeatedly. Louse-borne rickettsialinfections have incapacitated entire armies sincethe 16th century, as discussed in depth in Chapter11, Rickettsial Diseases. The loss of soldiers to theline commander, whether due to missile injury,accident, systemic infection, or skin disease, has thesame effect: fewer soldiers available to accomplishthe mission.

Certain skin diseases such as immersion foot(discussed in Chapter 4, Immersion Foot Syn-dromes) or tropical acne (Chapter 3, Skin DiseasesAssociated with Excessive Heat, Humidity, andSunlight) often require extended recovery periodsor evacuation, thus compounding the problem.While diarrheal illness accounted for the highestnumber of admissions during the Vietnam conflict(skin diseases ranked third), the average hospitalstay for diarrhea was only 3 days, compared to an 8-day average for dermatologic conditions.1 Becauseof poor institutional memory, the history ofdermatology in military operations tends to repeatitself. The commentary in Chapter 2, Cold-InducedInjury, exemplifies this fact. We must relearn afterevery conflict that early diagnosis and treatment ofskin diseases, combined with close supervision,constant education, preventive measures, and ad-equate equipment, clearly are vital to preservingthe fighting strength.

World War I

A. N. Tasker wrote, in 1928:

Diseases of the skin, exclusive of dermatologicalmanifestations of venereal diseases, though ordi-narily considered to be of minor importance in sofar as danger to life is concerned, are of greatimportance to an army operating in the field, byreason of the noneffectiveness they cause.2(p551)

This assertion is strongly supported by statisticsfrom World War I. Although outpatient data are

not available, from 1 April 1917 to 31 December1919, 126,365 U.S. Army soldiers were hospitalizedfor skin disease.2 Recorded diagnostic categoriesand case frequencies for these admissions includedscabies, 34,134; other (unclassified), 20,270; fur-uncle, 19,958; abscess, 16,329; cellulitis, 12,824; ec-zema, 4,035; ectoparasitism, 3,269; herpes, 3,141;trichophytosis, 2,813; impetigo, 2,735; carbuncle,2,330; psoriasis, 1,506; erythema, 1,495; dermatitis,858; pityriasis, 579; and lichen, 89.2 Over 2 milliondays of service are estimated to have been lost byreason of skin disease alone.3

In World War I, skin diseases became notoriousbecause of the sickness and lost man-hours theycaused. In the British army in 1915, in the UnitedKingdom, 40.88/1,000 men were admitted for dis-eases of the skin and areolar tissue. In France andFlanders, the rate was 126.13/1,000.4 For one Brit-ish army in France during the later stages of thewar, the more common diseases were scabies, infec-tions of the skin, and pyrexia of unknown origin,and these conditions accounted for 90% of all sick-ness.5 Because insect bites and infestations arecommonly secondarily infected, pyoderma andpyrexia often arose as related problems. Troopswith lice infestations were not admitted to sick callbecause disinfection was practiced as a routineamong field forces; nevertheless, the majority oftroops had pediculosis.2

In the U.S. Army in the United States and in theAmerican Expeditionary Forces in France, derma-tology was combined with urology. In The SurgeonGenerals Office, a section of the Division of Infec-tious Diseases and Laboratories was devoted tothese combined areas.2 Specialists were assignedto each camp and large hospital in the UnitedStates. The American Expeditionary Forces Divi-sion of Urology and Diseases of the Skin had asenior consultant in urology and two consultants indermatology.2

In general, both in the United States and in France,hospitalized patients with skin diseases weretreated on the general wards or on the venerealdisease wards.2 In a few hospitals in the UnitedStates, wards were set aside solely for treating skindiseases. During the spring and summer of 1918,some field hospitals attached to combat divisions ofthe American Expeditionary Forces operated as skinhospitals.2


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World War II

During World War II, because many nonderma-tologic physicians failed to appreciate the impor-tance of correct early diagnosis and early adequatecare of skin diseases, dermatoses frequently devel-oped to a stage at which weeks or sometimesmonths of duty time were lost before the soldiercould return to duty.6 The correct decision as to thedisposition of a soldier with a cutaneous disease(evacuation, limited duty, or return to combat duty)was often difficult to make. In these circumstances,a well-qualified dermatologist would have been ofimmense value.6

However, prior to mobilization in 1940, not asingle qualified dermatologist served in the U.S.Army Medical Corps, and army hospitals did notinclude a department of dermatology6 or even havea single medical officer with a cursory knowledgeof dermatology assigned.7 Tables of Organizationof army hospitals had no provision for a derma-tologist.7 A Consultant in Dermatology to the Of-fice of The Surgeon General was not appointed untilApril 1945, shortly before the end of the war, al-though many theaters had excellent consultantswho played very important roles in organizing der-matologic services and outpatient care.7 As the U.S.Army Medical Corps grew to a total of 48,319physicians, it included 107 board-certified derma-tologists, 30 fully trained but not board-certifieddermatologists, and 151 officers with some dermat-ologic training.6

During the early phases of U.S. involvement inWorld War II, Major General James C. Magee stated:

Skin diseases are of greater importance in militaryservice than in civil life. Although there are fewfatalities from these diseases they result in a con-siderable loss of effective manpower and partialincapacity of a material number of the personnel ofmany commands.8(pvi)

Conservative estimates hold that between 15%and 25% of visits to an outpatient department werefor skin disease in a temperate climate. This pro-portion increased to 60% to 75% in a tropical cli-mate.6

In May 1945, in the southwest Pacific, numerousdispensaries show as many as three fourths of thosereporting to sick call were suffering from diseasesof the skin.6 From 1 November 1944 to 1 November1945, approximately 14% to 16% of all patient evacu-ations to the United States from the southwest Pa-cific were due to diseases of the skin.6 During all

months, skin disease was a more frequent cause ofevacuation than battle casualties.6 In many generalhospitals located in tropical overseas areas, 15% to20% of admissions were for skin diseases.6 In oneevacuation hospital in the Pacific, 54.8% of theevacuations for general medical causes were forskin diseases.9

Among the Royal Air Force, Royal Australian AirForce, Royal New Zealand Air Force, and RoyalCanadian Air Force training in Canada during thewar, diseases of the skin and cellular tissue wereamong the top six causes of both morbidity andwastage (time loss).10 In the two New Zealand Expe-ditionary Forces in the Middle East, skin diseaseaccounted for 10% of total hospitalizations.11 Forthe Royal New Zealand Air Force in the PacificTheater, more men were unfit and more time waslost from skin diseases than from any other type ofdisease. Twenty-eight percent of the medical ad-missions in the area were on account of skin dis-ease.11 To put this in perspective, during the first 8months of 1945, 1,000 cases of skin disease werereported in a force of 7,800. Nearly 100 of thesesoldiers were hospitalized for more than 3 weeks,and 79 had to be repatriated to New Zealand.11

Few prevalence figures from World War II areavailable. An excellent prospective study of Britishsoldiers in Malaya and Hong Kong shortly after thewar revealed that of 1,694 soldiers examined, 79.5%had dermatoses of the feet; 33.5% had tinea corporis,tinea cruris, or both; 28% had prickly heat; 13.9%had acne; and 1.9% had nonbullous impetigo.12

Vietnam Conflict

Statistics for hospital admissions and outpatientvisits are more complete for the Vietnam conflictthan for any other in which the United States hasbeen involved,1 although many experts believe sub-stantial underreporting of outpatient informationtook place because of political pressures on com-manders during the war.

Skin diseases were the single greatest cause ofoutpatient visits to U.S. Army medical facilitiesduring the entire Vietnam conflict.1,13 There were1,412,500 recorded visits for skin diseases, twice asmany as for any other category of disease.1 Skindisease was probably significantly underreportedbecause most troops suffering from pyoderma andfungal infections were placed on light duty andnever appeared in reported statistics. One of thegreatest medical causes of combat ineffectiveness inVietnam was cutaneous disease.1,13,14 In some line


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units in the Mekong Delta, man-days lost fromcombat duty secondary to cutaneous disease ex-ceeded losses from all other causes combined.14

Skin disease had far greater impact on front-linemilitary units, with relative sparing of troops ingarrison. Hot, humid conditions and poor hygienemagnified this disparity. The U.S. Ninth InfantryDivision operated in the Delta region in southernSouth Vietnam and suffered the greatest impact.Forty-seven percent of the total man-days lost to thedivision in a 1-year period (19681969) were due toskin disease.1 This figure includes battle wounds,nonbattle injuries, and disease.1 More significantly,in actual infantry battalions, 80% of the man-dayslost in this division were due to skin disease.1

Of all soldiers seeking medical treatment for skindiseases during the Vietnam conflict, fewer than 1%were hospitalized. Cases were selected for hospi-talization based on the disease severity, refractori-ness to outpatient treatment, and interest to thephysician. This procedure was in direct contrast tosuch diseases as malaria and hepatitis, for whichhospitalization was routinely practiced. In thiscontext, the following hospital statistics are evenmore impressive. By category of disease, skin dis-ease was the third leading cause for admission,ranking behind diarrheal disease and respiratoryinfections.1 Malaria was the fourth leading cause.1

From 1965 through 1972, 45,815 soldiers were ad-mitted by all medical officers for skin disease.Pyoderma, eczema, cystic acne, and tinea led the listof diagnoses for admission.1 Of soldiers hospital-ized by dermatologists, 20% to 25% were evacuatedfrom Vietnam: a total of 4,166 soldiers.1 This figurerepresents 9.7% of all evacuations from Vietnam fordisease.1

Lessons Not Learned

Lessons not learned relating to skin disease havearisen from inadequate organization and training.The following section contains quotations from theofficial histories of warfare in this century thatconvey many common themes. We clearly have notlearned or have not acted on lessons relating to thedermatologic problems from one conflict to thenext.

Organization

The Table of Organization and Equipment (TOE)of todays army hospitals in almost all instancesdoes not contain a position for a dermatologist, a

situation identical to that at the onset of World WarII. Furthermore, no positions exist for dermatolo-gists in division, corps, or army medical staffs.Outpatient dermatologic care is almost totally ne-glected at division level and below. Corps assetsare severely lacking.

In 1947, Pillsbury and Livingood warned, con-cerning the U.S. Army in World War II, that in anymilitary organization of greater than 100,000 troopstrength, the surgeon in charge should have anadvisor in dermatology. They envisioned that thedermatologist would be assigned to a hospital butshould be called on for advice regarding the overallpolicies relating to cutaneous diseases in the com-mand, and should visit units at intervals to deter-mine the incidence of dermatologic disease and beof assistance to the unit medical officers.6

Cautionary advice was not directed solely at theUnited States. In 1953, W. R. Feasby, in commentingon Canadian forces in World War II, wrote that eachcommand should have the service of a dermatolo-gist, as should each large concentration of person-nel of all three services. He further stated that eachcorps or army should have a senior dermatologist,with one or two junior specialists available perdivision.15 Duncan and Stout,11 in an official historyof New Zealand in World War II, remarked thateach hospital unit in an overseas force should havea skin specialist on its staff.

The British army was better organized fordermatologic care than other Allied forces in WorldWar II. The British followed their consultantsrecommendations in organizational structure.He advised that on the staff of the Director ofMedical Services of each army there should be anadvisor or consultant in dermatology. A funda-mental part of the policy adopted in organizing adermatologic service was that fully equipped cen-ters, each under the aegis of a trained dermatolo-gist, were available, and that evacuation of casesto these centers was rapidly achieved. Further, ineach corps a dermatologist was available whoseactivity was not entirely confined to work in a skinclinic. He had authority to travel about the corpsarea and to instruct unit medical officers on theprevention, diagnosis, and treatment of cutaneousdisease.4

Training

With todays emphasis on specialization, the ever-decreasing number of flexible or rotating intern-ships, and the lack of required rotations in derma-


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tology in the medical education of a large majorityof physicians and medical students, we remainpoorly trained to care for dermatologic diseases.Regarding diagnostic skills in the U.S. Army inWorld War II, it was noted that many physicianshad so little opportunity for dermatologic trainingin medical school and internship that they wereunable to arrive at a diagnosis of even the simplestconditions of the skin.6

Up-to-date, specialized publications on derma-tologic diagnosis and care in a field environmentare important to supplementing the knowledge baseof all military physicians and physician assistants.In Washington, D.C., in 1942, at the instigation ofthe U.S. Army and the Committee of Medicine ofthe National Research Council, the preparation of asimple manual dealing with the diagnosis and treat-ment of cutaneous diseases commonly encounteredwas completed.6,8 This small textbook manual wasdistributed to nearly all medical corps officers inthe U.S. Army, Army Air Corps, and Navy. Manywartime hospital reports carry the statement thatdermatologic disabilities could have been cut inhalf if treatment methods had been improved andpatients had been brought into early contact with adermatologist.7

R. M. B. MacKenna, writing about the Britisharmy in World War II, remarked that a poorlytrained healthcare provider could do more harmthan good:

It is important to realize that usually the greatesthazard to which a patient who is suffering from acutaneous disease is exposed during the first stagesof his malady is that he is treated by a unit (regimen-tal) medical officer who, as he has had no specializedtraining in dermatology, may be uncertain of thediagnosis, and therefore may conduct treatment bya method of trial and error. This method is success-ful only in a few cases. In the majority it leads toan aggravation of the disability or dermatitismedicamentosa and eventually to an unnecessarily prolonged period of hospitalization.4(p159)

Commenting on skin diseases in the U.S. Army inVietnam, A. M. Allen observed that the lack ofemphasis on education and training in dermatol-ogy was undoubtedly responsible for a large por-tion of the morbidity caused by skin diseases. Thislack of emphasis was not apparent in other medicalfields of importance in tropical warfare, such asmalaria and enteric diseases, but seemed to be at-tributable to a general lack of appreciation for theenormous losses of manpower that can result from

cutaneous diseases. He concluded that, with theexception of dermatologists, the medical personnelwho were called upon to diagnose, treat and pre-vent skin disease in Vietnam had little if any train-ing in dermatology.1 In Vietnam, until the appear-ance of a field manual on skin disease in 1969, verylittle relevant information was available, and someof what was available was misleading. The manualpublished in 1942 was long outdated.

Recommendations

To provide first-rate military medical care and topreserve the fighting strength of our soldiers bypreventing as well as treating skin diseases, wemust address three areas of weakness that havebeen important historically: organization, training,and research. We must reorganize our TOEs, up-grade our training efforts to train healthcare pro-viders adequately about the importance of skincare in the field, and reestablish significantresearch efforts to solve lingering and recurrentdermatologic problems.

Organization

Working closely with the Combat DevelopmentsDivision of the U.S. Army Medical DepartmentCenter and School, we must reexamine TOEs formedical forces. A dermatologist should be on thestaff of all larger TOE hospitals. Corps-level assetsshould have a dermatology team with adequatevehicle support to travel about the corps and divi-sion areas to evaluate, teach, and treat. One seniorconsultant dermatologist should be assigned tocorps staff and should direct teams that provideoutpatient care to divisional level troops, ensuringthat two dermatologists are available in each corpsteam for each division supported. A theater con-sultant in dermatology and a dermatology teamshould be assigned for all troop deployments greaterthan division level, unless deployment is to a tropi-cal area, in which case a consultant and team shouldbe assigned for brigade-size and larger deploy-ments. Early prevention and outpatient treatmentcan prevent many of the medical casualties experi-enced in prior conflicts. A change in the Profes-sional Filler System (PROFIS) approach to desig-nating dermatology specialists is necessary, in whichdermatologists would be assigned to dermatologyteams or consultant positions. While this change isbeing instituted, consideration should be given toassigning dermatologists to Division Preventive


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Medicine Officer positions in the PROFIS system.Sets, kits, and outfits (SKOs) must be updated toensure appropriate dermatologic therapeutics andsupplies for all levels, from the company aidmansbag through dermatology team sets.

Training

Mandatory rotations in dermatology should beestablished for all military nonsurgical interns andresidents to provide a significant base of knowl-edge for the diagnosis and treatment of commonskin diseases. Military medical training centersmust ensure that a core curriculum for dermatologyresidents and medical students covers the commonskin diseases and does not emphasize only the rareand unusual diseases. There should be continuedwork with the American Academy of Dermatologyin establishing a core curriculum in dermatologyfor nondermatologists. A manual of dermatologyfor physicians patterned after the National ResearchCouncils World War II manual8 covering commondermatologic problems and their treatment shouldbe published, widely distributed, and periodicallyupdated. Universal distribution to military physi-cians of such a manual should be ensured as is donefor the The Emergency War Surgery NATO Handbook.16

The dermatology consultants input into basic medi-cal training for corpsmen should be ensured.

Research

Since the demise of the Department of Dermatol-ogy Research at the Letterman Army Institute ofResearch, The Presidio, San Francisco, California,in 1980, almost no research relating to field prob-lems and skin disease has been conducted by theservices. Research efforts should be reestablishedthrough the U.S. Army Medical Research and De-velopment Command to address better field diag-nosis and treatment of common disabling dermato-logic conditions such as pyoderma, fungal infections,and miliaria. An in-depth review of bathing avail-ability and requirements and their relationship toskin disease should take place. A method of fund-ing should be developed to allow military trainingprograms in dermatology to send small researchteams to locations such as the Jungle Warfare Schoolin Panama, where field studies can address real-time problems. The military should resurrect, fur-ther develop, and field better protective and pre-ventive items of issue such as shower thongs forwear by troops in base camps to decrease suscepti-bility to foot problems.1,9

PRINCIPLES OF DIAGNOSIS

The advantage a medical officer has in caring forthe soldier with skin disease is that the abnormali-ties about which the complaint revolves are usuallyvisible, and may also be palpable. In the perfor-mance of the direct examination, key clues must becarefully noted by a discerning, educated detective.Additional observations that can aid in solving thediagnostic mystery are easily gained by examiningthe skin and mucous membrane sites not directlycalled into question by the soldier, and throughdirected questioning. Laboratory tests taken asstandard of care in a hospital, such as potassiumhydroxide preparations, Tzanck preparations, cul-tures, and skin biopsies, may not be readily avail-able in the field. Thus, maximum use of informa-tion gained by close, educated inspection isnecessary.

Anatomy

Knowledge of the normal anatomy is essentialbefore the healthcare provider can understand der-

matologic terminology and principles of diagnosis.The skin is composed of three basic layers: theepidermis, the dermis, and the subcutaneous tissue.The epidermis is the most superficial and thinnestof the three; however, it is the principal site avail-able for inspection. A key finding in proceedingthrough differential diagnostic possibilities will bebased on the pivotal answer to this question: Isthere epidermal involvement? Normal epidermis issmooth-surfaced and has skin lines running throughit at regular intervals. With the notable exception ofthe palms and soles, most areas have small, regu-larly placed openings through which hairs grow. Itshould be appreciated that most cells that composethe epidermis are keratinocytes, whose primaryrole is to provide a physical barrier to externalforces. A smaller subset of cells is concerned withpigment production. These cellsmelanocytesgive the skin its normal color but can be damagedafter inflammation or may proliferate, leading tothe potentially deadly growth, melanoma. Althougha third group of cells exist, the Langerhans cells,


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which provide immunological surveillance, thesecells are rarely important in observational diagno-sis of the conditions discussed in this text.

The dermis is the site of residence of most com-ponents of the skin. Within this 1- to 4-mm area lieblood vessels, nerves, glands, hair follicles, andstructural matrix. This tough but flexible layer oftissue provides for temperature regulation, sensa-tion, and natural lubrication, and gives to the skinmany of the cosmetically important characteristicsvalued by all of us. Abnormalities of the dermis thatwill provide clues to the diagnostic dilemmas posedmost commonly in the field environment involvevascular dilation and inflammation. A blanchableredness of the skin implies that one or both of thesechanges have occurred. A nonblanching rednessusually results from extravasation of erythrocytesinto the dermis secondary to vascular damage.

A noninflammatory thickening or growth con-fined to the dermis (with normal overlying epider-mis) usually occurs from a benign or malignanttumor of existing normal structures or from aninfiltrative disease. In most cases, a biopsy is re-quired to make a definitive diagnosis. The impor-tance of these sporadic conditions to military medi-cine is minor. The key diagnostic intervention, theskin biopsy, is often deferred unless the lesion isgrowing rapidly or numerous sites are involved.Dermal tumors and infiltrative diseases will gener-ally not be discussed in this textbook.

The third layer of the skin, the subcutaneoustissue, is composed primarily of fat cells and pro-vides insulation, cushioning, and a reserve energysource. In general, disorders of the fat are of lesserimportance in the field due to their sporadic nature.Skin biopsy is usually required for definitive diag-nosis.

Physical Examination

Of the numerous diagnostic clues available to thephysician, the morphologic characteristics of thelesions are often the most helpful. They providea useful means of categorizing disease states andallow generation of a meaningful differentialdiagnosis. Once the primary lesion is recognized,other characteristics obtained by observing second-ary changes, configuration, regional distribution,and associated nondermatologic signs as well ashistorical information will quickly narrow thepossibilities. To use this approach, physiciansshould employ the basic vocabulary that definesprimary and secondary skin changes as well as

special lesions and configurations, as presented inFigures 1-1 through 1-19. It is in these words thehealthcare provider needs to tell the story of skindisease because, if the end of the diagnostic trailcannot be successfully reached, consultationcouched in these terms will be most rapidly andreliably regarded.

Such obvious information as age, sex, race, andregional distribution (covered vs sun-exposed, flex-ural vs extensor, truncal vs extremity) needs to beconsciously noted and included for consideration.Finally, inspection of the skin is not complete unlessdetails of any alteration in color, consistency, orgrowth pattern of hair and nails are noted. Themucous membranes are to be viewed as importantsites of ancillary clues to the diagnosis and shouldbe examined closely in all soldiers who present withskin disorders.

Patient History

Although the physical characteristics of skin le-sions provide the most critical information leadingto diagnosis, a historical account of the evolutionof the disease is important not only to understandthe disease process better but, often more vital, toallow soldiers to express their unique, individualconcerns to the physician. All soldiers desire acorrect diagnosis and effective medication for theircondition, but equally crucial in most cases is theindividualized education given to them by a sin-cere, concerned, thoughtful physician. Only byallowing soldiers to tell their stories can this beaccomplished.

In nearly every encounter, the duration and evo-lution of the disorder, as well as any previoustherapy that may have altered the natural course,need to be elicited. Skin-related symptoms, par-ticularly with regard to itching or pain, as well asassociated, concurrent, systemic symptoms; pastmedical history (especially as related to oral medi-cation and allergies); family history; and social his-tory may be important in individual cases. Themedical officer needs to understand (a) how thedisease affects the soldier (does it impair function,alter sleep, or cause cosmetic concern?); (b) thereason the soldier sought care; (c) suggested causes,diagnoses, or therapies; and (d) the main concern ofthe soldier (eg, Is it cancer? Am I going to givethis to my friends? What did I do to cause this?Can I avoid [anything] to make myself better?).All of these are of paramount importance in history-taking.


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Differential Diagnostic Considerations

The algorithms included in this chapter (Figures1-20 through 1-25) are presented for the nonderma-tologist in the field who is tasked with the care ofsoldiers without laboratory or skin biopsy capabil-ity. The algorithms address only some of the mostcommonly seen skin diseases. These diagnosticroad maps make use of classic characteristics of thedisease categories depicted. Many variations from

the standard presenting physical findings exist;therefore, these algorithms are not foolproof. Theydepend on the medical officers recognition of theprimary or predominant physical findings. Once adiagnosis is reached, the appropriate section of thisbook can be referred to for further information.Useful tests or additional information that will helpto confirm the diagnosis have been added next tothe algorithm endpoints; the tests can be obtainedwhen support is, or becomes, available.

Fig. 1-1. Primary versus secondary lesions. Primary le-sions are the earliest alterations present. With the pas-sage of time, changes may occur leading to less diagnos-tic secondary lesions. Reprinted from the AAD Library ofTeaching Slides with permission from the American Acad-emy of Dermatology. Fig. 1-3. Vesicle and bulla. Blisters containing clear fluid.

Vesicles are the smaller of the two, with bullae being0.5 cm or larger. Reprinted from the AAD Library ofTeaching Slides with permission from the American Acad-emy of Dermatology.

Fig. 1-2. Macule. A flat change in color of the skin.Reprinted from the AAD Library of Teaching Slides withpermission from the American Academy of Dermatology.

Fig. 1-4. Pustule. Yellowish cloudy fluid is present. Re-printed from the AAD Library of Teaching Slides withpermission from the American Academy of Dermatology.

Fig 1-1 is not shown because the copyright permis-sion granted to the Borden Institute, TMM, does notallow the Borden Institute to grant permission toother users and/or does not include usage inelectronic media. The current user must apply to thepublisher named in the figure legend for permis-sion to use this illustration in any type of publica-tion media.

Fig 1-3 is not shown because the copyright permis-sion granted to the Borden Institute, TMM, does notallow the Borden Institute to grant permission toother users and/or does not include usage inelectronic media. The current user must apply tothe publisher named in the figure legend forpermission to use this illustration in any type ofpublication media.

Fig 1-2 is not shown because the copyrightpermission granted to the Borden Institute, TMM,does not allow the Borden Institute to grantpermission to other users and/or does not includeusage in electronic media. The current user mustapply to the publisher named in the figure legendfor permission to use this illustration in any typeof publication media.

Fig 1-4 is not shown because the copyright permis-sion granted to the Borden Institute, TMM, doesnot allow the Borden Institute to grant permissionto other users and/or does not include usage inelectronic media. The current user must apply tothe publisher named in the figure legend forpermission to use this illustration in any type ofpublication media.


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Fig. 1-7. Wheal. Edema causes a transient papule orplaque to occur. Reprinted from the AAD Library ofTeaching Slides with permission from the American Acad-emy of Dermatology.

Fig. 1-5. Papules, nodules, and tumors are palpable skinlesions of varying size. Papules are less than 0.5 cm indiameter, nodules larger. Tumors are very large growths.Reprinted from the AAD Library of Teaching Slides withpermission from the American Academy of Dermatology.

Fig. 1-6. Plaque. An elevated, flat-topped lesion whosewidth exceeds its height. Reprinted from the AAD Li-brary of Teaching Slides with permission from the Ameri-can Academy of Dermatology.

Fig. 1-8. Scale. Dry, usually whitish flakes on the surfaceof the epidermis. Reprinted from the AAD Library ofTeaching Slides with permission from the American Acad-emy of Dermatology.

Fig 1-5 is not shown because the copyrightpermission granted to the Borden Institute,TMM, does not allow the Borden Institute togrant permission to other users and/or does notinclude usage in electronic media. The currentuser must apply to the publisher named in thefigure legend for permission to use this illustra-tion in any type of publication media.



Fig 1-8 is not shown because the copyrightpermission granted to the Borden Institute,TMM, does not allow the Borden Institute togrant permission to other users and/or doesnot include usage in electronic media. Thecurrent user must apply to the publishernamed in the figure legend for permission touse this illustration in any type of publicationmedia.


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Fig. 1-11. Lichenification. A thickening of the epidermisleading to accentuated skin markings.

Fig. 1-12. Atrophy. A thin, wrinkled, often depressedarea resulting from loss of skin tissue.

Fig. 1-10. Fissure, erosion, ulcer. Fissures are thin lineartears in the epidermis. An erosion is a wider-based loss of aportion of the epidermis, while an ulcer is larger and deeper.Reprinted from the AAD Library of Teaching Slides withpermission from the American Academy of Dermatology.

Fig. 1-9. Oozing and crusts. Oozing consists of tissue fluid,often with cellular debris, exuding from acutely inflamedskin. Crusts are usually moist, yellowish debris and appearwhen the fluid from vesicles, bullae, pustules, or oozingdries. Reprinted from the AAD Library of Teaching Slides withpermission from the American Academy of Dermatology.


Fig 1-11 is not shown because the copyrightpermission granted to the Borden Institute,TMM, does not allow the Borden Institute togrant permission to other users and/or does notinclude usage in electronic media. The currentuser must apply to the publisher named in thefigure legend for permission to use thisillustration in any type of publication media.


Fig 1-12 is not shown because the copyrightpermission granted to the Borden Institute, TMM,does not allow the Borden Institute to grantpermission to other users and/or does notinclude usage in electronic media. The currentuser must apply to the publisher named in thefigure legend for permission to use this illustra-tion in any type of publication media.


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Fig. 1-13. Comedo. Commonly called blackheads orwhiteheads, these keratin-filled hair follicles are the ear-liest lesions of acne. Reprinted from the AAD Library ofTeaching Slides with permission from the American Acad-emy of Dermatology.

Fig. 1-14. Telangiectasia. Enlarged superficial blood ves-sels. Reprinted from the AAD Library of Teaching Slideswith permission from the American Academy of Derma-tology.

Fig. 1-15. Burrow. The scabies mite will leave a lineartrack as she moves through the epidermis. Reprintedfrom the AAD Library of Teaching Slides with permis-sion from the American Academy of Dermatology.

Fig. 1-16. Scar. New formation of connective tissue as areparative process due to damage to the dermis or deepertissues. Reprinted from the AAD Library of TeachingSlides with permission from the American Academy ofDermatology.



Fig 1-15 is not shown because the copyrightpermission granted to the Borden Institute,TMM, does not allow the Borden Institute togrant permission to other users and/or does notinclude usage in electronic media. The currentuser must apply to the publisher named in thefigure legend for permission to use thisillustration in any type of publication media.



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OK to put on the Web



Fig. 1-17. Poison ivy will often cause linear lesions due tobrushing of the plant against the skin or spreading of theallergen by scratching.

Fig. 1-18. Grouped vesicles on an erythematous basecharacterize herpes simplex as well as herpes zoster.

Fig. 1-19. An annular arrangement describes a ringlikelesion that surrounds a central area of more normal-appearing skin.


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Yes No

Acne Perifollicular?

Yes No

Location? Crusts?

Yes No

Rosacea Flexural orOccluded Skin?

ImpetigoG, C

FolliculitisG, C

CandidiasisK, C

Beard orextrafacial

Central face

Yes

C: CultureG: Grams stainK: Potassium hydroxide preparation (KOH)

Fig. 1-20. Pustular lesions are often a sign of bacterial or fungal infection. Grams stain, culture, and potassiumhydroxide analysis will aid in the diagnosis of these conditions.

Comedones?

Pustules


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Vesicles and Bullae

Yes NoGrouped? Linear?

No YesYes

Herpes SimplesT, C

Herpes ZosterT, C

Allergic Contact DermatitisBx, P

Irritant Contact DermatitisHx

No

Widespread?

Yes No

Chicken PoxT, C

Autoimmune DiseaseBx

Bullous ImpetigoG, C

Porphyria Cutanea TardaBx

DermatomalDistribution?

C: CultureBx: BiopsyG: Grams stainHx: HistoryP: Patch testT: Tzanck smear

Fig. 1-21. Blisters may be a sign of infection; however, in a field environment they are likely to be secondary to irritantor allergic contact dermatitis.


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No

Melanoma:Bx soon

NoYes

EpidermalInvolvement?

Dermal Tumoror Cyst:

Bx Usually Elective

No Yes

TranslucentSurface?

Multiple SmallLesions? Warty Surface?

Yes

Yes No No

Wart Bx

Squamous Cell Carcinoma(Look for crusted orulcerated surface on

hard nodule)Bx

Basal CellCarcinoma

Bx

MolluscumContagiosum

CP, Bx

Pigmented?

Fig. 1-22. New or changing growths do not often require immediate attention in the field, as they are usually slow intheir development.

New or Changing Growth

Yes

Bx: BiopsyCP: Crush preparation with microscopy


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Widespread?

Scalp, Retroauricular,Eyebrows, Nasolabial

Folds?

No

Herald Patch?

PityriasisRosea

BxSeborrheicDermatitis

Superficial FungalInfection:

Tinea PedisTinea CrurisTinea ManumTinea CorporusTinea Faciale

K, C

Syphilis(Look at palms,soles, and oral

mucosa)Bx, VDRL, Hx

Reddish-brownpapules

Silvery scales onpink baseWhitish macules

Psoriasis(Look at scalp,elbows, knees,

and nails) Bx, Hx

TineaVersicolor

K

Color?

Fig. 1-23. A number of disorders exhibit scaling papules, plaques, and patches. Superficial fungal infections areextremely common in tropical environments. Syphilis is important to recognize because treatment will prevent long-term sequelae and spread of disease.

No Yes

YesNoYes

Scaling Papules, Plaques, and Patches

Bx: BiopsyC: CultureHx: HistoryK: Potassium hydroxide preparation (KOH)

VDRL: Veneral disease research laboratory test (Syphilis serology)


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Widespread?

PrimarilySun Exposed?Fever?

Viral Exanthem(Look at oral

mucosa)Hx, SS

Drug EruptionHx, Bx

LupusErythematosus

Bx, ANA, SS

Cellulitis(Look for warmth,tenderness, fever)

CANA: Antinuclear antibody

Bx: BiopsyC: CultureHx: History

SS: Systemic symptoms

Fig. 1-24. Macular erythema is a usually acute event that may worsen and even cause death if not recognized. A papularcomponent may sometimes be present.

NoYes

NoYesNoYes

Macular Erythema


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Lichen Planus(Look at oral mucosa,

lavender color)Bx

Predominantly onGenitals, Fingers,

Waist, and Buttocks?

ScabiesS

Randomly Distributedand

Asymmetrical?

Insect Bites(Look for groupingand central puncta)

Hx, Bx

Primarily Truncal?

Yes

Milaria RubraHx

Bx: BiopsyHx: HistoryS: Scraping with microscopy

Fig. 1-25. Pruritic, inflamed papules are among the most common types of skin lesions. Itching is intense, and thelesions commonly show secondary changes such as excoriations and crusts.

Pruritic, Inflamed Papules

NoYes

NoYes

No


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SUMMARY

Skin diseases are a significant cause of combatineffectiveness, morbidity to soldiers, and poormorale. Their importance to military operations ismost pronounced in tropical and subtropical cli-mates, where over half the man-days lost to front-line troops are directly related to skin disease. Al-though these facts have been repeatedly observedand recorded in official histories from World War I,World War II, and the Vietnam conflict, the U.S.Army today remains largely unprepared to prevent

skin disease or provide expert dermatologic medi-cal care in tropical operations.

Reevaluation of Tables of Organization andEquipment and Professional Filler System policiesis highly recommended. Increased research onthe prevention and early treatment of skin dis-eases is sorely needed. Finally, training of non-dermatologists in the basics of skin care, preventivepolicies, and dermatologic diagnosis needs to beaccomplished.

REFERENCES

1. Allen, AM. Skin Diseases in Vietnam, 196572. In: Ognibene AJ, ed. Internal Medicine in Vietnam. Vol 1.Washington, DC: Medical Department, US Army, Office of The Surgeon General and Center of Military History;1977: 2, 2930, 3435, 42.

2. Tasker AN. Diseases of the skin. In: Siler JF, ed. Communicable and Other Diseases. In: The Medical Department ofthe United States Army in the World War. Vol 9. Washington, DC: Medical Department, US Army, Office of TheSurgeon General; 1928:551557.

3. Lane CG. Medical progress, military dermatology. N Engl J Med. 1942;227:293299.

4. MacKenna RMB. Special contributions on military dermatology. British Med Bull. 1945;3:158161.

5. MacPherson WG, Horrocks WH, Beveridge WWO, eds. History of the Great War, Medical Services, Hygiene of theWar. London, England: His Majestys Stationery Office; 1923: 68111.

6. Pillsbury DM, Livingood CS. Experiences in military dermatology: Their interpretation in plans for improvedgeneral medical care. Arch Dermatol and Syph. 1947;55:441462.

7. Pillsbury DM, Livingood CS. Dermatology. In: Havens WP, ed. Infectious Diseases and General Medicine. In:Havens WP, Anderson RS, eds. Internal Medicine in World War II. Vol 3. Washington, DC: Medical Department,US Army, Office of The Surgeon General; 1968: 543588.

8. Pillsbury DM, Sulzberger MB, Livingood CS. Manual of Dermatology. Philadelphia, Pa: WB Saunders Company;1942: vi.

9. Grauer FH, Helms ST, Ingalls TH. Skin infections. In: Hoff EC, ed. Communicable Diseases Transmitted ThroughContact or by Unknown Means. In: Coates JB Jr, ed. Preventive Medicine in World War II. Vol 5. Washington, DC:Medical Department, US Army, Office of The Surgeon General; 1960: 83137.

10. Feasby WR, ed. Organization and campaigns. In: Official History of the Canadian Medical Services, 19391945. Vol1. Ottawa, Canada: Queens Printer and Controller of Stationery; 1956: 391427.

11. Duncan T, Stout M. War Surgery and Medicine, Official History of New Zealand in the Second World War, 193945.Wellington, New Zealand: War History Branch; 1954: 688703.

12. Sanderson PH, Sloper SC. Skin disease in the British army in S.E. Asia. Part 1. Influence of the environment onskin disease. Brit J Dermatol. 1953;65:252264.

13. Blank H, Taplin D, Zaias N. Cutaneous Trichophyton mentagrophytes infections in Vietnam. Arch Dermatol.1969;99:135142.


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14. Allen AM, Taplin D, Lowy JA, Twigg L. Skin infections in Vietnam. Milit Med. 1972;137:295301.

15. Feasby WR. Clinical subjects. In: Official History of the Canadian Medical Services, 19391945. Vol 2. Ottawa,Canada: Queens Printer and Controller of Stationery. 1953; 123132.

16. US Department of Defense. Bowen TE, Bellamy RF, eds. The Emergency War Surgery NATO Handbook. 2nd rev.Washington, DC: GPO; 1988.

military dermatology, chapter 1, historical overview and

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